Individual
IDA LEE ROACH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
5319 N 48TH ST, MILWAUKEE, WI 53218-3432
(414) 915-4926
Mailing address
5319 N 48TH ST, MILWAUKEE, WI 53218-3432
(414) 915-4926
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
309438-031
WI
Other
Enumeration date
10/22/2008
Last updated
10/23/2008
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